Many different causes

Doctors speak of erectile dysfunction (ED) when, over a period of at least half a year, no erection is achieved in 70 percent of »attempts« or an erection is so weak that penetration is not possible. The most »normal« risk factor for erectile dysfunction is age: unfortunately, around half of men over the age of 60 suffer from erectile dysfunction, and one in ten men aged between 40 and 49. However, researchers assume that the number of unreported cases is high because the issue is usually painful and embarrassing for men, which is why they don't always bring it up with their doctor. In many cases, something can be done to improve the stability of the penis. The first step is to find the cause. This applies to every age at which erectile dysfunction occurs. According to a study by a research team at Valparaiso University, Indiana, the (frequent) use of pornography has no effect on erectile function. And masturbation does not have a negative effect either.

The psyche, on the other hand, has a major influence, especially in younger men with ED. Depression, anxiety disorders and long-term stress, for example, can affect erections. However, men are less likely to ask for help than women, especially when it comes to mental health. This is shown by studies and figures, such as those from the hkk (commercial health insurance company) from 2022, according to which only a third of those insured who had contact with a psychotherapist were male. Men are also less likely to call in sick due to mental health problems than women. The awareness of the right to be emotionally distressed and to seek help still lags behind the reality among men. This is despite the fact that psychotherapy or sexual health treatment could have a positive impact on the problem. The »Internists on the Net« recommend involving the person with whom the affected man is sexually active in psychotherapy if possible.

In older men, 90 percent of cases are due to organic causes. If ED creeps into sexual life, this may indicate that the smallest blood vessels are undergoing arteriosclerotic changes and simply not enough blood is getting into the penis to make it swell. ED is therefore always a warning sign for the condition of the heart and circulation. This is because arteriosclerosis, which first manifests itself in ED, can also stop the blood flow in the cardiovascular system and cause heart attacks and strokes. This is one of the main reasons why men with ED should not simply order a little blue pill on the Internet - which is not advisable anyway for reasons of drug safety - but should consult a doctor.

One possible distinction between psychological and physical causes of ED is the extent of nocturnal erections. They are part of a man's physiological repertoire and are already evident in infancy, so they have nothing to do with sexual behaviour. These REM sleep-dependent erections often lead to the morning erection that men notice when they wake up. If they notice that this erection no longer occurs at all or only very rarely, then this indicates an organic rather than a psychological event. 

In addition to arteriosclerosis as an important cause of ED, other possible causes include diabetes, Parkinson's disease and dementia. Problems with erections can also occur alongside neurological diseases such as multiple sclerosis (MS), be associated with benign enlargement of the prostate and be the result of certain operations. Medications that can impair erectile function include antidepressants, some medications for high blood pressure, antipsychotics and anticonvulsants as well as opioids.

If a man feels like having sex but cannot achieve an erection, phosphodiesterase inhibitors (PDE-5 inhibitors) can help, regardless of whether the cause is psychological or physical. The drugs sildenafil, tadalafil and vardenafil relax the smooth muscle cells in the erectile tissue, allowing blood to flow in and induce an erection. Possible but temporary side effects include headaches and stomach pains, facial flushing, nasal congestion and visual disturbances.

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